Clinical Care for LGBTQ Youth: Ethical Case Studies

March 14, 2023

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YCSC Grand Rounds March 14, 2023

Lisa Campo-Engelstein, PhD, Professor and Chair, Department of Bioethics and Health Humanities; Director, Institute for Bioethics & Health Humanities; School of Public and Population Health, University of Texas Medical Branch

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00:00Hello everyone. Thank you so
00:03much for braving the weather and coming
00:04to join us here as well as on zoom.
00:08I have a couple of announcements.
00:10Just a reminder that next
00:12week for grand Rounds, Dr.
00:13Endres Martin will be our speaker and he'll
00:16be talking about his experiences and his
00:19journey in psychiatric medical education.
00:22So please come next week. Additionally,
00:25if you are hoping to get CEU for today,
00:28we have a new system,
00:30so in addition to using the text.
00:33Number to log on.
00:34Make sure at the end of today's
00:37presentation that you log off
00:40and that you also take the quiz,
00:43which is very easy.
00:46And everyone should take the
00:49quiz to test your knowledge.
00:52I am so delighted today to introduce
00:55to you our notable speaker,
00:57doctor Lisa Kampel and Goldstein.
01:01And she has come bravely all the way
01:04from Texas, originally from Albany,
01:06so she's not too unfamiliar with
01:09the inclement weather today,
01:11having received her BA in
01:13philosophy at Middlebury College,
01:15her PhD.
01:17In philosophy from Michigan State University,
01:20and most recently she has been appointed
01:23as the Harris L Kempner Chair in
01:27Humanities and Medicine Professor.
01:30She is also chair of the Department
01:32of Bioethics and Health Humanities
01:34at the University of Texas Medical
01:37Branch and the Institute for
01:39Bioethics and Health Humanities,
01:41where she is director of the
01:44Institute for Bioethics and Health
01:46Humanities and a professor.
01:47In the School of public
01:50and Population Health.
01:51And I heard Doctor Lisa speak
01:54to the broader pediatric Ethics
01:56Committee last spring,
01:57and I said we have got to have her here
02:00as well. And so here she is today.
02:03And so without further delay, welcome.
02:11Thank you so much, Lori,
02:12for the kind words and for having me here.
02:15I'm delighted to be here.
02:16I was supposed to come in the fall,
02:17but you know, I made it and that's OK.
02:19So, so glad to be here with all of you.
02:23So I will just jump right in.
02:24I'm supposed to stay
02:25within a little zone here,
02:26so I'm going to try.
02:27If I wander, Karen is going to let
02:30me know because I tend to get a
02:32little excited and moving around.
02:34But why don't I just start with and let's
02:37see if this is going to hopefully work.
02:40I want to start with some levity.
02:43Because we're going to be talking about
02:44some heavy issues here.
02:46So as this is my background,
02:48I'm not a clinician, OK?
02:50I'm a philosopher,
02:51but all the work I do,
02:54it comes from feminist and queer bioethics.
02:56This is me at a pride event last year.
02:59I don't know if you can read the shirt,
03:00it says can't think straight.
03:04And so this is me hitting the roller
03:06skating rink before all the students
03:07arrived because I didn't want to
03:09embarrass myself and fall down.
03:10So I did a couple loops and then I said,
03:13OK, I'm too old for this.
03:15But that just so you know that all my
03:18work stems from that sort of framing
03:20and that much of my work actually deals
03:23with reproductive ethics as well,
03:25some of these topics.
03:26So a lot of the very controversial topics.
03:30So that's why I wanted to
03:31have a little levity here.
03:32And you can see my ridiculous outfit.
03:35OK, so that's my quick background.
03:39The other thing I wanna say is,
03:41again, I'm not a clinician.
03:42I'm a philosopher,
03:43although I went into bioethics because
03:46I didn't want to just read dead white
03:48men and I wanted to collaborate.
03:50And I think there's so much
03:52value in getting people from
03:53different disciplines together.
03:55So I list up here some of the
03:57collaborations I've done with clinicians,
03:59with scientists, with social scientists,
04:01with all sorts of people.
04:03Because if you're ever interested
04:05in collaborating, please reach out.
04:06We have a great group.
04:08We love to collaborate.
04:09I've done a lot of collaborating with Laurie.
04:10Children's and Chicago since
04:12I did my postdoc there.
04:15But yeah,
04:15I think that's really important to know
04:17that I don't have all the answers.
04:18But I think when we get a handful of
04:20people together from different backgrounds,
04:22we can get closer at least.
04:24And that's the other thing I should
04:25say is I don't have all the answers.
04:27People are usually like,
04:28well, what should we do?
04:30And philosophers.
04:31If you walk away with more questions than
04:33answers, then we've done a good job.
04:35And I know that's infuriating,
04:37but we will try our best here.
04:40OK, So what are we actually doing today?
04:43We are going to identify some of the
04:46health disparities queer folks face.
04:48I'm going to say queer as an umbrella
04:50term so I don't get stumbled over LGBTQ.
04:53Plus I right,
04:54it's going to say queer.
04:56We're going to talk about some
04:58of the clinical,
04:59ethical considerations I
05:00played for queer youth,
05:02and then how can we provide high quality,
05:04inclusive care for all?
05:05So I know many of you are
05:07already experts in this,
05:08so I'll try to keep some of this short.
05:10And focus on the ethical issues.
05:12And I don't have any disclosures
05:13except for I'm happy to be here
05:15and it's nice to see Snow.
05:19So I believe you are all
05:21pretty familiar with this.
05:22I don't need to go into too much
05:24detail about gender identity,
05:26how it's different from gender expression,
05:28attraction and whatnot.
05:29OK, so I'm just going to cruise
05:31through that unless OK, good.
05:32And then of course we have all these
05:34different terms and they're constantly
05:36changing and evolving because language
05:38is changing and evolving, right?
05:40So I learned some new ones too
05:42when I was putting this together.
05:44But so for the most part,
05:46I'm just going to say queer.
05:49As you all know,
05:50the number of folks who identify as
05:52queer has been rising dramatically
05:53and some people are saying,
05:55oh, this is due to, you know,
05:57our society falling apart.
05:59I think this is just doing
06:01more social acceptance, right?
06:02My grandfather was left-handed
06:03and every time he tried to right
06:06with his left hand he got smacked.
06:08But when his kids when my father
06:10was growing up.
06:11Left hand, that was more accepted.
06:12There were more people in school
06:13who are left-handed.
06:14So when things become more socially
06:15acceptable and my father was
06:17disappointed that I'm not left-handed,
06:18he was hoping like to continue the
06:21trend and sorry, but as we become,
06:24you know,
06:24accustomed to different ways
06:26of being different people,
06:27people feel more comfortable being out,
06:29whether it's left-handed or queer right.
06:32And so, not surprisingly though,
06:33it's young folks who are most
06:35likely to be out.
06:36So you know, all of this,
06:37I don't need to go into too much detail,
06:39but just want to have that background.
06:42OK, So what are we going to do?
06:44We're going to do some cases.
06:45I think this will be more fun than,
06:47you know, again, dead Whiteman philosophers.
06:49I I worry some people think, oh, philosophy.
06:51She's just going to like,
06:52quote Socrates and it's going
06:54to be really boring.
06:55No,
06:55we're going to try to do
06:57this as applied as possible.
06:59So we have our first case and
07:00these are based on composite cases,
07:02real cases that I've worked
07:04on with clinicians.
07:05OK, so they are informed by the real world.
07:08We have Zach, he him.
07:10He's 16 and his parents are concerned he
07:13hasn't really been acting like himself.
07:16So.
07:18Again,
07:18I feel like I'm preaching to the choir here,
07:19so hopefully this is not too
07:21boring and redundant for you all.
07:23You all know that there is concern
07:26about coming out right at all ages,
07:29especially when you're young
07:30and you're dependent upon your
07:32parents or your guardians,
07:34and so there can be depression
07:36and anxiety around that.
07:38So Zach here is closed at home
07:41and he's bullied at school
07:43because people think he's queer,
07:44but he hasn't publicly come out.
07:47And so, you know,
07:49he's like this little picture here,
07:51like is it safe yet?
07:51When is it safe for me to come out?
07:53And This is why his parents
07:55are picking up upon is that
07:57he's been really withdrawn.
07:58What's going on here?
08:01So we know there's an increased
08:03stigma for being out,
08:04especially in certain places where
08:06it's less acceptable to be queer.
08:09I hung up a pride flag on my house
08:12and I was really worried about it,
08:15and thankfully it's been OK.
08:16But all the other houses next
08:17to me have Trump banners.
08:19So it's like Trump, Trump, Trump,
08:20a pride flag. Trump, Trump.
08:23You know, and, and I thought,
08:25well, we'll see what happens.
08:26And I'm a grown adult with lots of privilege,
08:29right? But there is this,
08:33this stigma associated with it.
08:34And this can lead to all sorts of health
08:37problems where you're less likely to get
08:38the care that you need because you're
08:40not going to see the health care provider.
08:42Or if you are,
08:43you're not telling them what's going
08:44on because you're scared, right?
08:46OK, so you know,
08:47one thing when I teach the medical students,
08:50I always tell them is to ask
08:53about sexual identity and gender,
08:54sexual orientation and gender identity,
08:57because so often they're not asked.
08:59And the reason most people don't
09:01disclose is because they're not.
09:02It's not that they're embarrassed,
09:04shamed, but what we see is in studies
09:06that people are willing to answer,
09:08including cysts,
09:09straight folks are willing to answer.
09:12There was a study done here.
09:15And I have something, oops,
09:16some of the citations.
09:17This is why I told you I need
09:18the non spill water bottles.
09:19I get too excited where they did a study
09:21in the ER of folks and ask them their
09:24sexual orientation and gender identity.
09:26And 90% of all people,
09:28this is again anyone that came into the
09:30ER was we're happy to say what they was,
09:32right.
09:32The clinicians didn't think
09:34anyone was going to disclose.
09:35So there's this discrepancy between
09:37what clinicians think because
09:38they're worried I'm going to
09:40upset people or infringe upon it.
09:41And the patients were like,
09:43Oh yeah, you know,
09:43all sorts of intimate things about me,
09:44why not this too? Right.
09:46So just ask and normalize it, right?
09:49You all know this already though?
09:52And.
09:54What we're going to be talking about
09:55in all this discussion here is just
09:58this SIS heteronormative framework
09:59that our society exists within, right?
10:02So we have these various forces,
10:05discrimination,
10:05stigma,
10:06denial of rights,
10:08and all these combined together
10:10in this funnel to lead to health
10:12disparities for queer folks.
10:14And that's what's happening for Zach
10:16here and and so many other folks,
10:18is that it's these forces at play.
10:20It's not necessarily, you know,
10:22bigoted providers.
10:23But all these other things that are
10:26leading on the structural level.
10:28So how does this play out then?
10:31Well,
10:31that we know that queer kids are more
10:35likely to have problems in school
10:38and not just the standard academic problems.
10:41Whereas most St.
10:42kids are saying,
10:44well,
10:44you know,
10:45I'm having trouble with class
10:46and my grades are not good,
10:48where kids are saying things
10:50like I don't feel accepted
10:53by my family, there's bullying,
10:55there's all these sorts of things.
10:56So the concerns they're
10:58bringing are really significant.
11:00And again, this is because of this.
11:01Structure of the CIS
11:03heteronormative world we live in.
11:06OK, mental health.
11:07Again, you all know this,
11:10so I'll go through it really quickly,
11:12but the rates of experiencing
11:14mental health conditions is so
11:16much higher among queer kids.
11:18And it's not that being queer
11:20is inherently linked to having
11:21mental health problems, right?
11:23If you are a marginalized member of
11:26any group, you're more likely to
11:28experience these problems because,
11:30again, of the structural aspects.
11:33OK.
11:36And I know you're familiar with these facts,
11:38but I want to kind of make sure we set
11:40the stage here and this would be some of
11:42the information we would be eventually
11:44sharing with Zack's parents so they
11:46understand the severity of the situation.
11:48But we'll get to that.
11:49So, umm, you know much queer kids are
11:52much more likely to face violence.
11:54Than straight kids.
11:56Pretty significant here.
11:57They're more vulnerable.
12:00These are probably really tiny,
12:02so you can't read all of these,
12:04but what we see here is just a
12:06lot of bullying for queer kids and
12:09this unfortunately continues into
12:11adulthood where adults who are career
12:15report bullying as well in their
12:17workplace where they feel like they
12:19can't talk about certain things.
12:20So again, not unique here.
12:25And the school is supposed to
12:26be a safe environment where
12:28they can learn and flourish.
12:29But many, some states,
12:31including Texas, where I live,
12:33have that don't say gay law,
12:34and this prohibits teachers and staff
12:38from talking about queer issues.
12:40And so imagine going to school and not
12:43being allowed to talk about yourself, right?
12:45Or this aspect of yourself.
12:47Or to talk about your parents who are queer.
12:49And I was talking to some other
12:51folks earlier and just saying.
12:53Some of these laws are written
12:55so poorly for so many reasons,
12:57but one of which is like,
12:58you can't talk about sexual
12:59orientation or gender identity at all.
13:01It's but they're talking about
13:02straight folks all the time.
13:03It's this folks all the time when you talk
13:05about Santa Claus like he has a gender,
13:07right? All the kids have a gender.
13:09So really what they're saying
13:10is don't talk about, like,
13:12the weird ones, right?
13:13You can talk about sexual
13:14orientation and gender,
13:15but not like, not queer ones.
13:17So this is a real problem for kids
13:19when they don't see themselves
13:21reflected in school curriculum.
13:23There's other states here that
13:26have laws that parents can opt out.
13:28That's the the lighter orange one of any
13:32curriculum that deals with LGBTQ stuff.
13:34And so the green states are the ones
13:37that allow explicitly require inclusion.
13:39And you can see those are only
13:40a handful of states, right?
13:42So queer kids are really not seeing
13:45themselves modeled in the curriculum.
13:47And we know queer folks have
13:49been around forever,
13:50so that can be really detrimental to them.
13:54Family support, we know,
13:56is hugely important to queer kids,
13:59and that queer kids who are
14:01supported by their family tend to
14:03do just as well as CIS het kids
14:05who are supported by their family.
14:08Look at some of these numbers
14:09when you look at this,
14:10where only 1/4 of queer kids feel
14:13like they can be themselves at home,
14:15that's really hard if they they're
14:17getting bullied at school for being
14:19themselves and now they come home and
14:20they feel like they can't be themselves.
14:22And this is, you know.
14:23As you all know,
14:24you're a psychologist, psychiatrist,
14:25crucial developmental time for them,
14:28and they're hearing negative things
14:30from their family members.
14:32Again, real.
14:32And no wonder then,
14:34we see so many who are unhoused, right?
14:37OK,
14:38so let's move to some of the ethical issues,
14:40because you all know the background.
14:43What do we do here when Zach
14:45comes to us and says, look,
14:48I'm gay and I don't want
14:50you to tell my parents?
14:53And again, I'm not a clinician,
14:54so in some ways I have it really easy.
14:56I can stand up here and say
14:57this is the ethical thing to do,
14:59and I don't have to live it in that way.
15:00So I, you know,
15:01I really,
15:02I recognize how challenging this is
15:03for you all on a daily basis and how
15:06privileged I am and how much more
15:08leeway I have in talking about these things,
15:10because I'm not practicing it.
15:13So what do we do here?
15:16Well, we have this ethical obligation
15:18to confidentiality, right?
15:20But when can confidentiality be broken?
15:23And usually we talk about imminent
15:26harm to oneself or to others.
15:28And this in this case,
15:29we don't see any imminent harm,
15:31right?
15:32I mean,
15:32hopefully not that from what we
15:34know so far about him.
15:35And we have to think about this fragile
15:38child who is disclosing something to
15:40you that he's really scared about
15:42talking about with anyone else.
15:44And how would that affect your
15:45relationship with him if you were
15:47then to tell his parents, right?
15:49So I think in this sort of situation,
15:52we really should uphold
15:54confidentiality to the best we can.
15:57However, it can get tricky.
15:59And this is what we were,
16:00Laurie and I were talking a lot about,
16:01is law and ethics don't always
16:03go hand in hand, right?
16:05Maybe they should, but they don't.
16:07And you need to work within
16:09your legal framework.
16:10I would never, as an ethicist say,
16:12do the illegal things.
16:13I don't want to get you in trouble.
16:15I can say to you the ethical thing
16:16is different from the legal thing,
16:18but it's important to keep in mind
16:20what privacy is in place for these
16:23kids and what legal protection they have.
16:26So in some states, parents.
16:27We no longer see their children's
16:29records when they reach a certain age,
16:31like in California.
16:32When they reach 12,
16:33their parents cannot see their
16:35records anymore.
16:36But in other states,
16:37that's not the same thing.
16:39So now you're dealing with this
16:41other ethical dilemma of, well,
16:42what do I put in the medical records, right?
16:44Do I want to acknowledge that this
16:46child is clear in the records?
16:48What if the parents see it?
16:49But if I don't acknowledge it,
16:50this child may not get the
16:52best care that he needs.
16:53And so it's really kind of tricky
16:55of how do you manage this,
16:58and I wish I had the easy answers,
17:00but I don't.
17:00But we can talk about this,
17:01and I would love to hear your
17:04thoughts and how you handle these situations.
17:07OK.
17:07The other thing I want to bring up that
17:10I think that supports confidentiality
17:13is that there are already examples
17:16of cases where minors can get
17:19healthcare without parental involvement.
17:21Some of these have been reduced
17:23recently through the jobs,
17:25but sexual reproductive healthcare,
17:27so, you know, STI treatment,
17:29birth control, these sorts of things,
17:31mental health, substance use.
17:33For many reasons,
17:34kids can get this treatment
17:36without parental notification.
17:38One is the stigma associated with all this,
17:40right?
17:40Kids are not going to feel
17:42very comfortable saying like,
17:43hey, parents, I have gonorrhea,
17:45can you take me to the doctor?
17:46Right.
17:47So they're not going to go and
17:48see the doctor unless they know
17:50it's going to be confidential.
17:52So if things are stigmatized or
17:54they don't want their parents
17:55to know they're having sex or
17:57some of these are public health
17:59matters where things are contagious
18:00and can spread to others.
18:01And so we as a society take this
18:04utilitarian approach where we
18:05want to maximize the greatest
18:06good for the greatest number.
18:08So we say,
18:09let's allow kids to get this treatment
18:11without their parents notification, right?
18:14Notable exception is abortion in many
18:16States and more and more so birth control.
18:19But for some of these others your kids are
18:22you don't ever have to disclose parents.
18:24Right.
18:25OK.
18:25So I think that is a nice precedent,
18:27nice model upon which we can base our claim
18:31that we should keep this confidential exact.
18:34So what do we do then? Do we?
18:36So now we know we're going to
18:38keep a confidential right?
18:39Do we encourage Zach to
18:42disclose to his family?
18:45And this is a tough one because we know
18:47a lot of families are not supportive.
18:50And so are we going to cause Zach more harm?
18:55Will this lead to him being kicked out?
18:57Will this lead to verbal abuse?
18:59Well, what? You know, what will happen.
19:01And if we don't know anything about
19:03his family that I don't think
19:04we should make a recommendation.
19:05I think we need to gain more
19:07information and learn more about his
19:09family and also strategize so he has a plan,
19:12right?
19:12So he doesn't just come home one day and say,
19:14like, oh, by the way,
19:15I'm gay, hurray, you know?
19:17So I think this needs to be done carefully.
19:21And be strategic about how
19:22to do this and see
19:24what Zach thinks.
19:25What does he feel comfortable doing?
19:27Are there ways he can kind of float the
19:30idea beforehand and talk about these
19:32issues and not talk about himself?
19:34Right. But I I I don't think that
19:36we should push him to disclose to
19:39his family because of the danger
19:41that is possibly present there. OK.
19:44But we do want to make sure that
19:47he's getting support and there are
19:49all sorts of support systems out
19:51there and with the virtual world,
19:54there's more and more access.
19:56And what we see is a lot of kids want
19:58to get support but they don't know
20:00how because they don't have money or
20:02they need their parents permission.
20:04But now with the social media world
20:06that I am too old to understand,
20:08I know there are lots of options
20:09out there and you probably all
20:10know them very well.
20:11You're all probably like
20:13tick Tock famous already.
20:14But there are these,
20:16these places here for them to
20:17go to where these are credible
20:19sources where they can get support.
20:22And I think that's really important.
20:24You know, they came out to you.
20:26They might already feel isolated
20:27and vulnerable to make sure they're
20:29talking to their peers who are
20:31in similar situations,
20:32so these local and online support
20:33groups I think are really great.
20:36So let's Fast forward six months.
20:41Zach has come out to his family and it
20:45went OK, maybe better than expected.
20:48They didn't kick him out.
20:49They but they want him to try conversion
20:52therapy because they think, you know,
20:54being gay is this real problem and it's
20:56going to make him not have as good of a
20:59life and blah blah blah and their mind.
21:01And so they want him to try this.
21:03They also associate being a gay man
21:06with having HIV. So they say we want
21:08you on Prep just to protect you.
21:11We're worried about it.
21:12There's that. You know, again,
21:13they're buying into this
21:14cultural narrative of, like,
21:15gay men being super promiscuous and
21:17having sex with anything that walks.
21:19So they say, let's put him on prep,
21:21even though we're trying
21:21to get rid of his gayness.
21:24Their words, not mine.
21:26So conversion therapy,
21:27I'm sure you're all familiar with
21:30this is the idea that you use.
21:32Pseudoscience or spiritual methods or
21:35psychological pseudo psychological
21:36methods to change someone's sexual
21:38orientation or gender identity,
21:40right?
21:42And. About 10% of adults have
21:45undergone this in the US and it
21:49is not banned in many states.
21:52It and the green states,
21:53those are the places where it is banned,
21:55where it is not allowed.
21:57But in other states there's either
21:59no comment about it or it's allowed.
22:02And you know, we,
22:03we talked a little bit earlier today too
22:05about like ethics and trying to be neutral.
22:06And I'm not very good at being neutral
22:08about these things I'm passionate about.
22:09So I will just be blunt.
22:11I think it's absurd that gender
22:13affirming care has been classified
22:15as child abuse when the state of
22:18Texas allows conversion therapy,
22:20which we know is so harmful.
22:22And so again,
22:22I'm in a place of privilege where I
22:25can say that as an ethicist and they
22:26can't come after my license because I
22:28don't have one or anything else like that.
22:31I don't have any patience.
22:32I just have you all here.
22:34But that that just is horrifying
22:36to me that when we look at the
22:39evidence for conversion therapy
22:41versus gender affirming care,
22:43if you were just to look at it scientifically
22:45and they allow conversion therapy.
22:47So unfortunately,
22:48this is the real thing that still happens
22:51and parents are still trying to get
22:53their kids to go to conversion therapy.
22:55So I think we have an ethical
22:57obligation to tell the parents that
23:00you should not send your kid there.
23:02And to try to have a conversation with them
23:05about all the harms associated with this.
23:08Because you know, it's not,
23:11it doesn't really work and it's harmful,
23:13right. And so I don't think you can be
23:16morally neutral about a type of treatment,
23:18right that is going to do harm.
23:20So I think you really do need
23:22to take a stand here as well.
23:23Umm. And then prep.
23:26So they're concerned about HIV AIDS.
23:29And I think it's important here
23:31to distinguish between negative
23:32rights and positive rights.
23:34So negative rights are the rights
23:35to be left alone. Autonomy rights.
23:37My rights to do my karate
23:39stops where your nose begins.
23:41I can't punch you in the face, right?
23:43And don't worry, I won't.
23:44I'm not violent.
23:45But this idea that we have the right
23:48to do what we want with our body,
23:50and that's why we can't do
23:52procedures against people, you know,
23:53if they're refusing, it's considered battery.
23:55Our assault so this is almost
23:59absolute in medicine.
24:00Almost.
24:01There are some cases if someone
24:02has very contagious Ebola,
24:04we might quarantine them.
24:05But for the you know, otherwise,
24:07we let people with COVID go out in public.
24:09We let people do all sorts of things.
24:11So I have real concerns though
24:13about forcing treatment on
24:15someone against his wishes,
24:16even if he's a minor.
24:21Oh, I'm sorry. Yes, thank you.
24:23Prep is a prophylactic to
24:26prevent HIV taking daily.
24:28It can prevent the likelihood
24:30of of acquiring HIV. Aids that.
24:32OK. Thank you. Yes, please.
24:33And feel free to chime in if there's
24:35things I'm missing or questions.
24:36Great. So, you know,
24:39I think even he's a child,
24:41he has negative rights and we
24:43should not force him to take a
24:46medication against his wishes,
24:47even if he is sexually active.
24:49And in this case, Zach was saying,
24:50no, I'm not sexually active at all.
24:52So it makes no sense because
24:53they're always going to be some
24:54side effects with medication.
24:55Why are you going to put this kid on the
24:57medication if he's not sexually active?
24:58If it's just because the parents are scared
25:01because they associate being gay with HIV,
25:03that's not a good enough reason.
25:05And again,
25:06I think we need to really support
25:08individuals bodily integrity and
25:09make sure that we are not doing
25:11things to them against their wishes,
25:13even if they are minors,
25:15even if they lack capacity,
25:17even all these situations,
25:18I think we have to think very carefully.
25:20About when we can infringe
25:22upon people's bodily autonomy.
25:24OK.
25:24Great.
25:25So some other reasons why
25:27I think we should not,
25:29we should say no to prep
25:30is it's not life saving.
25:32This would be a different situation
25:35if he were bleeding out and he was
25:36saying I don't want blood products,
25:38right?
25:38This is the classic bioethics case
25:40of the Jehovah's Witness family
25:41and the kid needs a transfusion.
25:43If that were the case,
25:44we would say this is all imminently
25:46life threatening situation.
25:47Give this kid blood.
25:49This is not the same case here, right?
25:51He's not sexually active and there are
25:53other ways to prevent HIV transmission,
25:55right?
25:55Condoms and spermicides and
25:57all these other things.
25:59So I think that's a bad idea.
26:01Also, just the logistics of forcing him.
26:03How are we going to do this every day?
26:04Are we going to tie him down and
26:07make sure he takes this pill?
26:08He's, you know, I.
26:11Big kid.
26:12This is going to be really challenging.
26:14How do we know he's not
26:15gonna throw it up later?
26:16And I think just the psychological harm
26:19of forcing people to take a medication
26:22against their wishes is significant,
26:24and we can't underestimate that.
26:26So I think this is just
26:27not going to be feasible,
26:28and I think it's also unethical to force him.
26:32OK.
26:34Hopefully you've all eaten,
26:36so the food is not too tempting.
26:38So some takeaways.
26:41Confidentiality is really, really important.
26:43You all know this.
26:45I'm preaching to the choir here.
26:47But when you, if you can uphold it,
26:49do so and think really carefully,
26:51carefully about cases where
26:53you would violate that.
26:54We need to support team decision making,
26:57especially when it comes to stigmatized care.
26:59They are coming to you as a safe place,
27:00as an ally.
27:01They are not going to other people.
27:03So we need to create that environment,
27:05which I know you're all doing the right to.
27:08Bodily integrity is hugely significant.
27:10There's lots of legal precedents
27:12and ethical precedent on this.
27:13So don't violate unless you have really,
27:16really, really good reasons to do so.
27:18And then encourage familial
27:20and social support.
27:22Should I take questions now?
27:23Just move to the second case,
27:25move to the second case.
27:25All right,
27:26we're going on.
27:30OK, we have Jackie here.
27:32She her 15 years old, assigned male
27:35at birth but identifies as female.
27:37Been on puberty blockers since 11 and
27:39she is super eager to start hormones.
27:41Can't wait and she wants
27:43to preserve her fertility,
27:44which we'll get to later on.
27:47OK, so what's going on here?
27:49Her parents are concerned.
27:52As we know, puberty blockers are reversible.
27:55It's kind of just putting a pause on things.
27:57But hormones are not.
27:59Hormones can lead to certain lifelong
28:01consequences and changes in one's body.
28:04So their parents are
28:05really worried about that.
28:06They strongly oppose bottom surgery.
28:08Well, good, because we're not doing
28:09bomb surgery on minors anyway.
28:11So all this stuff in the media,
28:12it's like genital surgery on 3 year olds.
28:14Not happening unless as I was talking with
28:16other folks about their intersex kids.
28:18And then we do that, which is also unethical.
28:21But I digress.
28:22So you know when we're really
28:24not doing bomb surgery on minors,
28:26so you can assuage their concerns about
28:28that and saying when they're eighteen,
28:29they can think about that.
28:32So and then fertility preservation,
28:34they say what a waste of money.
28:36Why do you need that?
28:38You know you should act according
28:40to your assigned gender,
28:41and if you're not going to do that,
28:42then you shouldn't have kids because
28:43it would be harmful to the children,
28:45blah blah blah.
28:46So they are, you know,
28:48they love their child,
28:49they're supportive of their
28:50child in many ways,
28:50but they're really concerned about
28:52this and not just psychologically,
28:54but also about the effect these
28:56hormones will have on their child.
28:59So who decides here in this type of case?
29:03So we have paternal beneficence, right?
29:06Parents who want to do well
29:07for their children.
29:08Again, it's not like parents are evil.
29:09Like, ha ha ha,
29:10let me make my child miserable, right?
29:12We know that's not what's happening here,
29:14but we also have jackies, autonomy.
29:16So how do we weigh these?
29:19And at what point do we listen
29:22to Jackie over her parents?
29:24And this gets tricky.
29:26But you know,
29:28the way I've tried to cash it out in my
29:29work and in conversations I have with others,
29:31is we need to look at the
29:33subjectivity of the treatment.
29:34If Jackie were to come in with strep throat,
29:38that's an objective test we can test
29:39for that we know how to treat that.
29:41We give them the drugs,
29:42we go on, blah, blah, blah.
29:44Same thing with a broken arm.
29:46It's clear we can test for
29:47that with an X-ray.
29:48OK, now we put the cast on.
29:50But for other things like gender identity,
29:53there's no test, right?
29:53We don't draw blood and say,
29:55Oh yes, congratulations,
29:56you really are a girl, right?
29:58So this is only something that Jackie
30:00can tell us that can come from her,
30:03can't come from anyone else.
30:05Same thing with things like reproduction,
30:07whether or not someone wants to
30:09have biological children that can't.
30:10Again, we can't do like an X-ray.
30:11And you're like, Oh yes,
30:12your eggs are ready and you
30:14want to have kids.
30:15So these are really deeply subjective.
30:18And so we need to listen to the children.
30:21Even more in these cases.
30:23And it needs to be coming from the kids.
30:26It can't be the parents and it can't.
30:29And this I think is really hard for a
30:30lot of parents because it does seem so
30:32subjective and everyone's like, well,
30:34subjective stuff is just squishy and but
30:35how do we know it's true and how do we know
30:37it's real and all these things and what,
30:39we'll talk about some of those things.
30:41But I have this chart here just to show that
30:44as things become increasingly subjective,
30:46we need to listen to kids more and more.
30:49So if that Blue Square is an app and,
30:50you know, appendicitis.
30:51We know what to do in appendicitis, right?
30:53We're not going to tell if the kids like,
30:55I don't want that because I
30:56want to wear a bikini. Too bad.
30:57We're getting your appendix out.
30:58OK. Sorry, kid, but if the kid,
31:01you know, the red lines here,
31:03says this is my gender identity,
31:05I think we need to listen there, OK?
31:08All right.
31:10And part of the way we support this and
31:13ethics is we talk about an open future.
31:16And this is the idea that we want to leave
31:19as many possibilities available for children.
31:22We don't want to limit what
31:25roads they may go down.
31:27So This is why, you know,
31:28we we don't do dramatic surgeries
31:30to children when they're young
31:32that might affect them lifelong,
31:34like some of the areas like surgeries because
31:35then it will close off certain paths,
31:37right.
31:37We want to keep.
31:38Things open so they can say yes,
31:40I choose this or no,
31:41I choose this and so that going
31:43back to the Jehovah's Witness case,
31:45that's part of the reason why
31:46we give blood products to minors
31:48who are Jehovah's Witnesses,
31:49because we want them to have an open future.
31:52So when they reach 18,
31:53they can say this religion is not
31:55for me and I'm glad I'm alive.
31:56Or they can say this religion is for me
31:58and I wish then give me blood products.
32:00But I guess I'm alive and I can
32:02decide on my own next time.
32:03OK,
32:03so this idea of an open future
32:06is really important.
32:08But sometimes when we're thinking
32:09about hormones we're doing,
32:11we're looking at omission versus
32:12Commission and people are saying,
32:14oh, but like, you know,
32:15if I give them hormones or puberty blockers,
32:17I'm the one interfering and
32:19I'm doing something to them.
32:21So I'm causing them harm.
32:23I think that's sort of that line of
32:26reasoning neglects that Natal puberty
32:27is harmful for some kids, right?
32:29If you assume Natal puberty was neutral,
32:32then yes,
32:32doing something that could change
32:34that could be harmful.
32:35But for many of these kids,
32:37Natal puberty is going to be really
32:39damaging and it doesn't have
32:41to be inevitable.
32:42We have the tools to change that,
32:44just like we have for other
32:46sorts of healthcare issues.
32:47We can change something that might be
32:49inevitable by treating it in advance,
32:51right?
32:51So Commission versus omission,
32:53I don't think that's an important
32:55distinction here,
32:55but sometimes people bring that up.
32:58The other thing to bring up is that
33:00puberty blockers are not permanent,
33:01so we can allow Jackie to go on them
33:03for a few years so she can grow and
33:05develop and see what she thinks.
33:07There is, of course a psychological
33:09delay to puberty.
33:10I mean, 9th grade is hard enough.
33:12Now imagine you're only one hasn't puberty.
33:15But again, when we're weighing harms,
33:17that might be the lesser.
33:22There are physical harms
33:24associated for Jackie here.
33:26If she's getting hormones on her own
33:28and dosing that, if she's talking,
33:30all these sorts of things that she's
33:32doing without intervention, without help
33:34from a care and healthcare provider,
33:36can be causing herself more physical harm.
33:39There are so many psychological harms we
33:41could spend forever talking about all these.
33:43Unfortunately again, bullying at school.
33:49More likely to use substances I had.
33:51I had to cut down some of these slides.
33:52Like way too many 1/4 attempts suicide.
33:55There's even numbers that are
33:57higher than that, even more here.
33:59All sorts of things.
34:01More likely to drink,
34:04more likely use marijuana, blah blah blah.
34:06I know these responders.
34:07Really tiny, huh?
34:08But I guess the point is.
34:11They are more at risk for
34:13all these sorts of things,
34:14for sexual violence, for substance,
34:16all this for bullying because of
34:19being transgender, if not, again,
34:20being trans that causes this.
34:22It's this structural,
34:23this heteronormative SIS,
34:24normative structure in which they live.
34:27So these psychological harms are enormous.
34:29I don't think we can underestimate
34:31how significant these are,
34:32and I know again,
34:33appreciation for the chair.
34:34There's also lifetime harms that we need
34:36to think about is that people who are
34:38trans are more likely to experience violence,
34:41more likely to be unhoused.
34:42And this disproportionately effects
34:44people of color who are trans.
34:46More likely to be incarcerated.
34:48All these sorts of things.
34:49So it's not just, oh, now I'm 18,
34:51I can make my own decisions.
34:53Hooray,
34:53this continues over a lifetime.
34:59Texas is Texas and there's all sorts
35:02of laws being introduced, as you know.
35:05What you can see from the chart on the
35:08right is the number of bills that have
35:10been introduced, anti trans bills.
35:12And look at how much it's increased
35:15over the last six years dramatically.
35:17The ones in pink are bathroom
35:19and locker room bills,
35:20the ones in blue are restrictions on care,
35:23and the Gray ones are just other ones.
35:25But. You know,
35:27I think as the conservative movement has.
35:30Had success with anti abortion
35:33rights legislation.
35:35They now need a new wedge issue and
35:37they are using anti trans legislation
35:39to fill that gap because these are
35:41very similar in a lot of ways.
35:43They are both pushing for this white
35:46supremacy gender binary understanding
35:48of the world where everyone has
35:50their clear roles and so they can
35:53get their base mobilized by talking
35:55about these sorts of things.
35:56And so it's not surprising that we
35:58see all these laws coming through
36:00we've already this was.
36:02This article was in February.
36:04350 anti trans laws in 36 states.
36:07I mean Can you imagine if those
36:09laws were for things like making
36:11sure kids get like food, you know,
36:14support and love,
36:15like think of all the good we could do.
36:17So, you know, again,
36:19I think this is really just a
36:21wedge issue to push this forward.
36:23So what are some of the objections
36:25to her gender affirming care?
36:26I'm sure you've seen this Texas
36:28classified as child abuse.
36:30Again, you know my feelings on that.
36:33You know,
36:33and sometimes this is hard to argue against,
36:36that people think they're there
36:37is this gender binary and God
36:39created woman and God created man,
36:41and this is they have different roles,
36:42I suppose, to do different things.
36:43And it is very hard to argue
36:45against people's religions, right?
36:46Doesn't matter if you give them the
36:48whole history and all the other things.
36:50But that is sort of the argument
36:53that's at play there.
36:54Another argument is that kids are
36:56not able to meaningfully decide.
36:59We let kids make all sorts of
37:01decisions that affect their lives.
37:02We let 13 year olds decide to
37:05stay pregnant or get, you know,
37:07because that's we think that's OK.
37:09Somehow, even if the child wants an abortion,
37:11we say, no, we're going to let you do this.
37:13Kids can make decisions for themselves,
37:16especially when they're about
37:18these subjective things,
37:19because only they know their values.
37:20And, yes, are their values perfect? No.
37:22Will their values change over time?
37:24Probably. Guess what? They're human.
37:26They're like all of us.
37:27These things change and develop.
37:29But you know,
37:29no one is better positioned to
37:31make these decisions than they
37:33are because it's about themselves.
37:34My potential for regret?
37:36We will get into that in just a second
37:39because this always comes up so.
37:42There's this idea of Desistance
37:44where children are we're starting
37:47on a a gender journey and then
37:50went backwards, OK?
37:51And so some people are saying, no,
37:53it really what's happening here is
37:55that these kids are regretting it.
37:57They're not mature enough
37:57to make these decisions.
37:58But that's not what we see in the literature.
38:01And the more recent literature shows
38:02that less than 4% of kids desist.
38:04There is some older literature
38:06out there that has some really
38:09problematic methodological features.
38:10I'm not going to go into all of that.
38:11But like, you know,
38:12if the kid never comes back to your
38:13clinic and you count them as a.
38:14Sister, maybe they just moved
38:16to another state, right?
38:17You can't just count them as that.
38:19But no, this is like interesting language.
38:21We have like a whole term for people who
38:24we see as changing their gender back again.
38:27I just,
38:28I find it really interesting that
38:30we did this all this like catchy
38:32language that can be used in the media
38:34to kind of push this debate forward
38:36and that these terms are culturally loaded,
38:38right?
38:39And they're morally loaded as well.
38:41So,
38:42but what we see again is that really most.
38:44Kids are persistent, not distant.
38:47And this has a lot of text, so I apologize.
38:51But even if people desist,
38:53it doesn't mean they regret it.
38:54And some but.
38:55So we need to separate
38:56regret from desistance.
38:58But I do want to take a second to talk
39:00about regret because there are lots of
39:02places where people regret their surgeries.
39:04I had knee surgery,
39:05I regret that surgery, and no one ever
39:07asked me whether I regret or not.
39:08No one seemed to care.
39:09But I regret it and I will go tell them,
39:11maybe one day.
39:14But look at all these other
39:16things these adult patient regret,
39:1827% who had moderate to severe
39:21regret after major head neck surgery,
39:2430% regret robotic assisted,
39:25you know prostate removal,
39:27all these people are having regrets.
39:31Nope.
39:32What's normally regulated though
39:34is elective hysterectomy.
39:35But they'll regret rate is so low for that.
39:38But all these,
39:39you know,
39:40ACOG had the American Congress of
39:42College of Obstetrics and Gynecology
39:44had to come out and say look,
39:46if if you have assist woman who wants
39:48instructed me and she doesn't have kids,
39:50you have to do it for her.
39:50You can't just be like sorry honey,
39:52you're going to want kids down the line.
39:53You're going to regret this
39:54because that's what was happening.
39:57And they don't regret it.
39:59Again, this is a very subjective thing.
40:01Only that person knows what they want.
40:04And yes, some of them may come to regret it,
40:06but that number is really small.
40:08But I don't hear any
40:09politicians or anyone saying,
40:11Oh my gosh, neck surgery.
40:12We got stopped that next surgery,
40:13everyone's regretting it. Never.
40:15But I do hear about hysterectomy, right?
40:18And so they're looking at
40:20pediatric and parental regret.
40:22What we see is that some kids do regret
40:25not being included in decision making.
40:27So the first step here is about quarter
40:29of a Y cancer patients regret that they
40:31were not included in decision making,
40:33that the parents and the clinicians
40:35made those decisions without them.
40:37About third regret, DSD surgery,
40:40differences of sex disorder and then again
40:42looking at another type of DSD hypospadias.
40:45A lot of parents regret doing that
40:47surgery and yet intersex surgery for
40:49babies is legal and accepted in the
40:52medical community despite the fact
40:54that his parents regret it and no one
40:56is thrown around that information.
40:58So I feel like we use this
41:00information to push forward sort of
41:02our political beliefs and agendas.
41:04OK, so there's lower regret.
41:07The numbers I'm seeing are under
41:101% for gender affirming surgery.
41:12And it's also important distinguishing
41:14why people might have regrets.
41:16Like, is it just medical?
41:18Like you don't like the way your new genitals
41:21look or you're not able to orgasm as easily?
41:23Is it social?
41:24Now you're having trouble getting along,
41:26you know, at work because you don't.
41:27People don't have to handle you.
41:29What's going on?
41:29Or is it really true?
41:31Oh my goodness,
41:31this is the wrong gender.
41:33And what we see is a lot of the reasons
41:35people determination is external pressures,
41:37social stigma, family pressure,
41:38these sorts of things.
41:39It's not that they change their mind.
41:43OK,
41:43so getting back to Jackie's supportive
41:47parents similarly are super important
41:50and this can make all the difference
41:53for trans and non binary kids.
41:56And So what we see here is that
41:58kids who are get to use the
42:00names they want do much better,
42:02and especially in all different arenas,
42:04home, school, whatnot.
42:06And that trans kids who are supported by
42:09their parents to just as well assist kids.
42:11Really what happens is if
42:13trans kids are not supported,
42:14then they do poorly psychologically.
42:17So it's all about providing them support.
42:21But there are these barriers
42:22to care for Jackie and others,
42:24things like parental consent.
42:28And This is why I think it's
42:29interesting as well is that,
42:31you know,
42:31we talked about some of these
42:33areas of medicine where kids
42:34can get treatment without their
42:36parents knowledge or or approval,
42:38but we don't allow that for gender
42:41affirming care and I don't see
42:43why not because I think there's
42:44a lot of similarities.
42:45This is stigmatized.
42:46This has to do with sexual
42:48sexuality and gender,
42:50which are very subjective and
42:51there have been some ethicists
42:53out there making the case that we
42:55should allow kids to get access to this.
42:58As well, like we do for STI treatment or
43:01contraception or all these other things.
43:03So I would welcome your thoughts
43:04on that too. When we talk.
43:05Some of the barriers to care too are
43:07just like the visibility of it, right?
43:08If you're taking birth control,
43:10no one may know, but if your body
43:12starts changing in certain ways,
43:14it's going to be obvious.
43:16Another huge barrier is just expense.
43:19These procedures are hugely expensive,
43:22and the states in orange are the ones
43:24where Medicaid explicitly says they will
43:27not cover any gender affirming care.
43:29So if your insurance doesn't cover
43:31it and you're on Medicaid, too bad.
43:34Texas, all right,
43:36I want to quickly come to fertility
43:40preservation because it's something else.
43:42Jackie was interested in gender affirming
43:44care because can cause infertility,
43:46infertility, and sterility.
43:47And there's an interesting New York
43:49Times article about this woman on
43:52the right hand side here who is
43:54trans and underwent gender affirming
43:57care and then detransition.
44:00So according to some of those stats,
44:01you would be AD transitioner so
44:03that she could produce viable.
44:04Firm so she and her partner could
44:06have a genetic related child and
44:07then she went back on hormones.
44:09So she talks about going through
44:10puberty multiple times.
44:11I think once was more than enough,
44:14so good for her.
44:17And this is where I think we can
44:18distinguish we talk about negative rights,
44:20autonomy rights, rights to be left alone.
44:22Positive rights are the right to something.
44:24So in this country there really
44:26isn't a positive right to healthcare
44:27except for an emergency situation.
44:29There is a positive right to
44:31K through 12 education some,
44:32and that means someone has to provide it.
44:34So the government provides it.
44:35We don't say anything about
44:36quality or whatnot,
44:37but someone provides it.
44:38So positive rights and medicine
44:40are pretty limited and there isn't
44:43a positive right to reproduction.
44:45There are in other countries and Israel,
44:48it's very pronatalist.
44:48And they will pay for you to have
44:50two live birth babies because they
44:52really want people having babies or
44:53certain types of people having babies,
44:55and many other European countries as well.
44:58They will even give you money to have kids.
45:00So they're trying to encourage that.
45:03And cost here is going to be a barrier.
45:06It's super expensive to just get the
45:09games retrieved and then to store them.
45:12It's hundreds of dollars each year.
45:14And this is not covered by insurance.
45:16And as far as I'm aware,
45:17there are no charity programs
45:18for trans folks.
45:19There are for folks with
45:21infertility and folks with cancer.
45:23So this is going to be really expensive.
45:24And what,
45:2515 year old has this kind of
45:27money to shell out, right?
45:29There are alternative
45:30family building structures.
45:32Again, these can be expensive.
45:33Adoption can cost easily 20 to 50 grand,
45:37and there are all sorts
45:38of discriminatory laws.
45:39So these, the yellow triangles,
45:41are states that refuse,
45:43that can where it's legal to
45:46refuse adoption to queer families.
45:49So, you know,
45:49if you're living in Texas and
45:51you're a queer family,
45:52state agencies can say,
45:53sorry,
45:54I'm not going to adopt you because you're
45:55not a suitable home for this child.
45:57So it, you know,
45:59there's extra barriers there for folks.
46:01So the case takeaways here are the
46:04subjectivity of gender affirming
46:05care and how this means I think we
46:08need to pay even more attention
46:10to the child's preferences.
46:12Again, supportive environment,
46:14I know you knew that.
46:15And then having those conversations
46:17early about reproductive autonomy,
46:19because what we see is that
46:21that's really important to a lot
46:22of young people and they never
46:23have those conversations.
46:24And often they're so eager to go on
46:27hormones and then they regret that later.
46:29So just having those
46:31conversations as soon as you can.
46:32So talk takeaways.
46:33These things are deeply personal.
46:35We need to listen to youth, and we need
46:38to be supportive and be advocates.
46:40All right.
46:41I will be happy to take any
46:42questions or comments.
46:49You so much. Thank you
46:51for leaving. Plenty of time
46:52for us to talk.
46:55Yes. Clarification, yes.
47:00And Amy ask, can you clarify
47:02in the states where conversion
47:03therapy is banned and is it banned
47:05for everyone or only for minors?
47:07Minors. Yeah, good question.
47:09Adults can do what they want,
47:11but minors is banned for.
47:19Could you just clarify what you said really
47:21fast at the end of the year?
47:23You said something like
47:24they regret that later.
47:26Was that about hormones, hormone
47:28therapy affecting fertility?
47:30So they sometimes regret not preserving
47:33their fertility, especially as they
47:35get older and learn that these.
47:37So a lot of them are interested in
47:39alternative family building options,
47:40which is great.
47:41But I don't think they realize when
47:43they're 15 that there's all these
47:45discriminatory practices that will
47:47prevent them from having kids.
47:49That way. And so. But you know,
47:51given all the conversations you have,
47:53that regret.
47:53I'm not saying that we should, you know.
47:55Push them to have fertility preservation.
47:57That's actually some of the other work I've
47:59done is what do we do in situations where.
48:02Teenagers don't want to have
48:03fertility preservation,
48:04but their parents do want them to have it.
48:06And how do we balance autonomy there?
48:09Because yeah, I mean,
48:10like most 16 year olds are worried
48:12about not getting pregnant right
48:14now about getting pregnant.
48:15And so I think there just needs to
48:17have a lot of conversations and just
48:19let kids know that alternative methods
48:21may not be a viable option for them,
48:23unfortunately.
48:26Thank you so much. We have a
48:27couple of questions from zoom.
48:29I see that Doctor Sheldon and please
48:31go ahead and ask your question.
48:38Hello. I'm actually Doctor Calhoun,
48:40but I'm here with Doctor Sheldon.
48:41We're in the same room.
48:42Uh my name is Amanda.
48:43I am a fourth year adult child
48:46psychiatry resident wanted to say I
48:48have a question actually and a comment.
48:49So first, you know,
48:51I appreciate your presentation.
48:52I would say, you know,
48:54I did find it a bit problematic that
48:56the family you chose to portray that was
49:00uneducated thought queer people spread
49:02HIV was a black or brown appearing family.
49:05I think it's very important to be mindful.
49:08That often black and
49:09brown parents are racist.
49:11They portrayed as less educated,
49:14less in the know.
49:15And personally I've had many white
49:17families that also think that.
49:18And actually that concept
49:19was started by white people.
49:21So I just wanted to add that.
49:23And my question for you is,
49:24you know, you mentioned I loved,
49:26you know,
49:27all the aspects of your talk.
49:29But I did find what was missing was
49:32an acknowledgment of white supremacy
49:34and the fact that oftentimes the
49:36queer folks who are elevated.
49:38Are white appearing?
49:39And my question for you is how are
49:41you collaborating with folks to
49:42take an anti racist lens to this?
49:44Because you know, you know you well,
49:47I appreciate you showing people
49:49of different racial backgrounds.
49:51There was really no mention of the
49:52fact that like black transgender
49:54people are the ones who are getting
49:56murdered at really high rates.
49:57The impact of racism and how
49:59that is also playing roles.
50:01I guess my question is how are you
50:03adding not just the CIS heteronormative
50:06agenda and pushing against that?
50:08But also the white supremacist agenda.
50:11Yeah. Thank you so much for that.
50:12And then just look at that camera, I think.
50:15Thank you so much for that question.
50:16I'm pointing that out,
50:17and I think you're absolutely right
50:18that we need to be mindful about that.
50:19So I appreciate that, that comment.
50:22So some of the things that I'm doing is
50:25working with some community groups where
50:28there are a lot of people of color in
50:31queer groups to advocate in that way.
50:34Because I think you are so right that,
50:36and I think I have that one tiny little
50:39diagram that showed you that like people
50:41of color who are queer are more likely
50:43to get this exacerbated in every way.
50:46Because of white supremacy.
50:47And it is white supremacy that you know
50:49has led to these gender binary the way
50:51we understand it in our culture now,
50:53so completely and there are many
50:55other communities where there
50:57are third genders and you know,
51:00communities of color are from
51:02around the world that where it's
51:04just totally acceptable.
51:05So I think that's a really important point.
51:07I try to work with, like I said,
51:10communities in my area who are of
51:13color and other underrepresented
51:14groups who try to work with really.
51:16A lot of rural folks who are queer because
51:18they're often really disadvantaged as well,
51:21and folks with disabilities.
51:22So trying to get other
51:24voices heard besides mine,
51:26because I recognize that, you know,
51:27as a white affluent woman,
51:29my views are often limited.
51:30So I need to hear other people's voices.
51:32Thanks.
51:39Thank you. I'm Lilia Benoit,
51:41Challand Allison psychiatrist.
51:44And I would like to ask you if if
51:48there was a component maybe on,
51:50on the first case for the parents
51:54willing to to implement the prep therapy
51:57like as a preventive therapy really
52:00do you think there might be
52:02something around making that
52:05their child experience?
52:07The difficulties and the challenges of having
52:11sexual and dating life as a queer person,
52:16I wonder about that because the
52:19the reason they explicitly said
52:21was they are worried about HIV.
52:24But from families I've been seeing,
52:28there was also sometimes
52:29this component of saying,
52:30like, oh, you know,
52:31life is more challenging when you're
52:33a career and you have to get used to it.
52:35And so maybe kind of.
52:37Along the line of conversion therapy,
52:39kind of showing the kid how difficult
52:41it is and all the side effects
52:44of having to take medication.
52:47So I just wonder if it's something you
52:49that was part of this case or it's
52:52something that that you also saw.
52:54Yeah.
52:55Yeah. No, thank you.
52:56And I think it was something we saw
52:58because the parents did love their
53:00child very much and they didn't want
53:02their child to live a life where they
53:04would be disadvantaged or hurt or
53:06anything like that or at greater risk.
53:07For certain things.
53:08And so I don't think it was just
53:10homophobia that led to this.
53:11I think it was your life is going to
53:14be a lot harder because you're going
53:16to face this type of discrimination.
53:18But I think the way Zach internalized that
53:22was you don't approve of me and who I am.
53:28So I think just having. Yeah, go ahead.
53:32Yeah, I think there's a
53:35question from Victoria stop.
53:38Oh, yes. Thank you.
53:40I just wanted to say thank you
53:42so much for this presentation.
53:44I found it really refreshing and
53:47I was curious your thoughts on so
53:50you talked a lot about teenagers,
53:53but you know gender development
53:55starts and happens much earlier.
53:57And I'm just curious about maybe
54:00some tips or strategies you might
54:02have for folks that are are working
54:05with kind of variance much earlier
54:07or family systems that are stifling?
54:10That variance,
54:12yeah, no, it's a great question.
54:16And there are a ton of books out there,
54:18so I'm not going to list them all.
54:19But for the can't remember when this book
54:22came out, but it's and tango makes 3.
54:24Maybe some of you are familiar with it, yeah.
54:27I've been giving that to
54:28everyone I know who has kids.
54:30They know they're going to get
54:31that book for me. And I have.
54:33It's a story of two Penguins.
54:34It's based on the real story
54:35at the Central Park Zoo.
54:372 male Penguins who mate and they keep
54:39sitting on rocks and none of their rocks,
54:41you know,
54:41crack and become a little baby Penguins.
54:43So they finally give them an egg and
54:45then they raise this baby and tango makes 3.
54:48It was my, like, subtle move.
54:50It's some of my more conservative family.
54:53And they're like, oh, Penguins, how cute.
54:55We were expecting something more
54:56controversial from you, Lisa.
54:57I'm like, oh,
54:58wait till you read this book.
55:00So I think there's a ton
55:03of resources out there.
55:06I think sometimes having it be somewhat
55:09innocuous and more palatable framing
55:11will help people listen to it a
55:14little more than they might otherwise.
55:16But I mean,
55:16I can always send you a list of stuff,
55:18but I would just look.
55:19There's just so much stuff to
55:20that answer that question.
55:23OK. Thank you.
55:27OK, I'll be.
55:31Go ahead. So I just,
55:33I wanted to just make sure I kind of got
55:35the right information.
55:37So in the state of Connecticut.
55:39The parent makes all the decision
55:41until the individual becomes 18.
55:44Unless it's birth control or so
55:47I'm kind of trying to figure out.
55:50Where does a kid get to decide
55:51in the state of Connecticut?
55:53Question is in the state of Connecticut,
55:55what medical decision making rights
55:57does do a child have and when?
55:59And in Connecticut as far as you can tell,
56:02I so I'm not a lawyer.
56:04Yeah, so sorry I can't answer that.
56:07What I can say is in most States and
56:09I would talk to your legal team here,
56:12in most states minors are allowed to
56:14make decisions independent from their
56:16parents regarding birth control,
56:18like regarding reproduction.
56:19Exception of abortion in a
56:21lot of places such sexuality,
56:23conception of gender affirming
56:25care but things like STI's,
56:28mental health and substance use.
56:30They are allowed to seek that
56:31type of care without their parent
56:33knowing or being notified.
56:34Does that align with what the
56:36clinicians in the room experience here?
56:38We have the director of our outpatient
56:40clinic here who can tell us at what
56:42age in our clinic can kids come for
56:44therapy and not tell their parents?
56:46Doctor Michelle Goyette Ewing.
56:49It's at 16 and
56:50you can only come for six sessions
56:52unless it can be documented that the
56:55child or youth would be at risk for
56:58disclosing that they were in treatment.
56:59And this is specifically for gender
57:01dysphoria. Or is this for all kids?
57:03OK, yeah. So the laws vary.
57:05So sorry, I you know.
57:08And I don't know them
57:09all in different places,
57:10but often those are the reasons why.
57:12Oops. This is why I need spill
57:15proof for any reason they can
57:16come in for up to six visits.
57:18OK, so that's broader than
57:19some other places, actually.
57:22I know when I was in New York,
57:23like the clinicians were allowed
57:25to give birth control to 12 year
57:27olds without their knowledge,
57:28without parental knowledge,
57:29because they treated them as
57:31independent or emancipated in some
57:32ways when it came to those decisions.
57:34So I would check your state
57:36laws and talk to a real lawyer.
57:41Well, we really appreciate all of the ways
57:44that you have empowered us today to be
57:47passionate advocates. Don't be neutral.
57:50Thank you. Thank you all.